HIV/AIDS: Legal & Ethical Issues

Transcription

1 NORTHWEST AIDS EDUCATION AND TRAINING CENTER HIV/AIDS: Legal & Ethical Issues Shireesha Dhanireddy, MD Presentation prepared by: S. Dhanireddy Presenter: S. Dhanireddy Last Updated: 12/18/12

2 Objectives: Understand basic biomedical principles of ethics Review physicians ethical principles (AMA) - Specifically, when can a provider disclose? - Common problems which present ethical dilemmas Understand protections to persons with HIV/AIDS Review behaviors endangering public health

3 Four Bioethical Principles: AUTONOMY - respect for the individual and their ability to make decisions about their own health and future. BENEFICIENCE - actions are intended to benefit the patient or others; NON-MALFEASANCE - actions intended not to harm or bring harm to the patient and others; and JUSTICE - being fair or just to the wider community in terms of the consequences of an action.

4 Case 1: Disclosure 40 year old male who discloses HIV status to his pastor who then proceeds to inform potential employer and coemployees of his HIV status. He asks you what can he do about this.

5 Case 1 Tell him there is no legal recourse against employer s actions Seek advice from public health officer Call local prosecutor Do not advise

6 Inappropriate Disclosure

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8 Example HIV/AIDS problems that require ethical consideration: Misperception, stigma, & discrimination AIDS legal issues (Washington State version): - Behaviors endangering public health (BEPH) often present the most difficult ethical issues - Mandatory testing for persons sentenced for drug and sexrelated crimes - Management of substantial exposures to health care and public safety workers, rarely requiring mandatory testing of sources Strong Public Health help to clarify the problem and provide ethical & moral assistance may be needed to help achieve HIV/STD control in some communities

9 Misperceptions persist & can harm persons with HIV Cirque de Soleil fired one of a male couple featured in The Advocate, because he was HIV+ -- a risk to other performers according to the Cirque (2003) JC Penney Store in Illinois fired HIV+ employee (2005) Foreign Service applicant denied position as officer based on HIV + status (2001) 13 year old HIV+ boy denied admission to private school (2012)

10 Stigma Exists High percentage of people at high risk who test for HIV in local public health, test anonymously. Most AIDS community supporters have strongly opposed HIV reporting by name despite significant public health benefits to HIV+s Many people with HIV will not disclose their HIV status to family and friends, let alone employers. Some with HIV do not disclose to sex and needle sharing partners at risk (whose status is HIV negative or unknown).

11 The 1988 Washington State AIDS Omnibus Law: Protections No person may require HIV (or HCV) testing as a condition of hiring, promotion, or continued employment unless the absence of HIV or HCV is a bona fide qualification for the job in question It is illegal to discriminate against persons with HIV/AIDS in housing, public accommodations, and credit It is illegal to disclose that a person has tested for HIV, or has tested positive for other sexually transmitted diseases, except for their medical care.

12 Despite Protections, Discrimination Still Exists Protections: Washington State AIDS Omnibus Law prohibits discrimination on the basis of HIV Americans with Disabilities Act prohibits discrimination on the basis of disabling conditions, such as HIV People with HIV are often unaware of their protections, unwilling to disclose their status, or too disempowered to seek help

13 Case 2 You discover that a 30 year old HIV+ male to female transgender has placed an ad in a local paper to offer escort services. She is also known to have multiple partners and is not disclosing her HIV status.

14 Case 2 What are your obligations? No obligation Notify public health Counsel her to disclose HIV status to partners, use condoms Notify the police

15 Case 2 Duty to warn - permissive disclosure - Does it apply in this case? Role of Public Health Role of Provider - Prevention with Positives

16 DUTY TO WARN - When may a provider disclose? Duty to protect patient s rights Duty to protect both patient and others Duty to not bring harm to patient and others Duty to be fair and just to the wider community

17 When may a provider disclose? When serious harm may occur to a third party, whether or not a criminal offense, e.g. threat of serious harm to a named person (e.g., Tarasoff decision) When a doctor believes a patient to be the victim of abuse and the patient is unable to give or withhold consent to disclose When, without disclosure, a doctor could not act in the overall best interests of a child or young person who is his/ her patient and incapable of consenting to disclosure When, without disclosure, the task of preventing or detecting a serious crime by the police would be prejudiced or delayed

18 Role of Public Health Partner Notification - Partner Counseling and Referral Services (PCRS) current terminology - Contact Tracing Behaviors Endangering Public Health - High proportion have co-morbidities (mental illness, substance abuse, e.g.) - Due process steps 1 st no anonymous reports; certainty of status & counseling messages being delivered Order to cease & desist Potential court action à detention (90 days max) Court actions beyond public health (based on victim s report)

19 Behaviors Endangering Public Health People who knowingly expose others to HIV may warrant some intervention. - Should it be a public health intervention? When knowing exposure to others is suspected, King County interpretation of state law defines three levels of public health response, under the phrase behaviors endangering the public health (BEPH).

20 WA State BEPH law requires three levels of response: Signed orders must be applied sequentially: 1st level = Order to Test for HIV with counseling; this documents the person s HIV status and the delivery of basic instructions on minimum safety standards 2nd level = Order to Cease and Desist from specified behaviors 3rd level = Detention Order for up to 90 days of intensive counseling in a non-jail facility; requires prior judicial review; has never been used in Seattle or King County

21 Factors Impairing Ability to Behave Safely: Major psychiatric diagnosis Developmental disability Current abuse of illegal drugs Current abuse of alcohol Current prostitution Current homelessness

22 Deficiencies in Current System Local public health officials can only contact patient for partner notification purposes and referral to social and health services. No mention of timing of contact, who has the primary responsibility, or duration of monitoring of ongoing potential at risk partners. Only practical intervention for public health risk is a cease and desist order or detention for 90 days and is only renewable if evidence of ongoing risk exposure. Problem arises when public health seeks enforcement of a cease and desist order but prosecutor chooses criminal actions: what public health records can the prosecutor access?

23 Careless Transmission More Common Transmission by BEPH is probably a relatively rare phenomenon Most transmission appears to result from carelessness: - People not thinking clearly, maybe from drugs - Or taking calculated risks (e.g., partner selection, strategic positioning) - Or, by avoiding disclosure

24 HIV Decriminalization Effort 34 states have criminal laws that punish people for exposing another person to HIV (whether or not HIV transmission occurs or if condoms were used) includes WWAMI states Effort at the congressional level to repeal these laws

25 General Public Health Messages to Give Patients: Disclose to partners (akin to informed consent) Disclosure protects you medically, legally and ethically Careless spread of HIV can lead to legal consequences, including court-ordered confinement

26 Summary Ethical issues in HIV/AIDS complex but important to address Established laws to provide protection for those with HIV Ongoing debate/dialogue of issues required Stay tuned for possible HIV decriminalization